History of Present Illness:  A 68 year old male presented to the emergency department of a small rural hospital.  He complains that he is "feeling bad" and his wife states that there is a foul odor coming from his foot ulcer.  Following the initial evaluation he was transferred the the VA Hospital.

Past Medical History:

  • Type 2 Diabetes Mellitus
  • Arrhythmia
  • Hypertension
  • Depression
  • Hypercholesterolemia
  • Constipation
  • Aortic stenosis
  • Decubitus Ulcer
  • Cerebral Vascular Accident (CVA 10/2000)
  • Hemorrhoids
  • MI during appendectomy / cholesystectomy (1/2001)

Social History:  He is a paraplegic with cognitive defects.  His wife the primary caregiver.  No smoking or alcohol use.

Medications Prior to Admission: Metformin Insulin, Human
Gabapentin Metoprolol Lisinopril
Simvastatin Amiodarone Sertraline
Bisacodyl Docusate Trazodone
Promethazine Ranitidine Metoclopramide
Nitroglycerin Meclizine ASA-EC
Ascorbic Acid Witch Hazel pad HC/pramoxine cream

Allergies:  Tylenol & Percocet

Physical Examination:

  • Foot Ulcer
                -LE pulses nonpalpable
                -No clubbing/edema
  • Hemorrhoids
  • Decubitus Ulcer
  • Dental Ulcer
  • Vitals:
                -Blood Pressure - 154/78
                -Pulse - 62
                -Temp - 97F
                -Respiratory Rate - 16
                -Weight - 86 kg  

Hospital Course:  Started on Vancomycin 1000 mg in NS over 60 min BID; Silver sulfadiazine cream BID to foot and peri-rectal ulcers; Ibuprofenin 600 mg q 6 h prn.

Triple Phase Bone Scan was ordered to differentiate between osteomyelitis and cellulitis.  20 mCi HDP was injected and images were obtained in the plantar view.

Blood Flow Study demonstrates poor blood flow to the extremities.  There is an increased activity in the affected area.

Blood Pool image demonstrates increased activity Delayed imaged has increased uptake in the area of the 5th metatarsal consistent with osteomyelitis.
  • Diagnosed with Osteomyelitis in the 5th metatarsal
  • Micro revealed Methacillin Resistant Staph Aureus (MRSA)
  • 5th metatarsal amputated
  • Started on enoxaparin inj.
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Images courtesy of UAMS Dept of Nuclear Medicine.